State Plan Home and Community Based Services

Provides HCBS to individuals who require less than institutional level of care and who would therefore not be eligible for HCBS under 1915(c). May also provide services to individuals who meet the institutional level of care.

Medicaid Requirements That May Be Waived:

Comparability

Community income rules for medically needy population

Application Process:

State plan amendment submitted on pre-print.

Preprint can be obtained from CMS Regional Offices

Approval Duration:

If not targeting: One-time approval. Changes must be submitted to CMS and approved.

If targeting: Renewal every 5 years.

Reporting:

Annual reports.

42 CFR §441.677(b) requires States to develop and implement a quality improvement strategy that includes methods for ongoing measurement of program performance, quality of care, and mechanisms for remediation and improvement proportionate to the scope of services in the State plan HCBS benefit and the number of individuals to be served, and make this information available to CMS upon the frequency determined by the Secretary or upon request.

Administration & Operation:

Administered by the Single State Medicaid Agency (SSMA).

May be operated by another state agency under an interagency agreement or memorandum of understanding.

Provider Agreements:

Required between providers and the SSMA.

Delegation allowed to a provider agency under the Organized Health Care Delivery System or Provider of Financial Management Services. Requires written specification of delegated activity.

Medicaid Eligibility:

All individuals eligible for Medicaid under the State plan up to 150% of Federal Poverty Level.

May include special income group of individuals with income up to 300% SSI. Individuals must be eligible for HCBS under a §1915(c), (d), or (e) waiver or §1115 demonstration program.

Other Eligibility Criteria:

For the 300% of SSI income group, must be eligible for HCBS under a §1915(c), (d), or (e) waiver or §1115 demonstration program.

Required if participant direction is offered. May be covered as a service, an administrative function, or performed directly by the SSMA.

Employer Status for Participant Direction:

Participant may be the employer of record under a Fiscal/Employer Agent model or the entity may be the employer of record under an Agency with Choice model.

Financial management supports are required to function as employer of record when the individual elects to exercise supervisory responsibility without employment responsibility.

Goods and Services:

Permitted as a service.

Direct Payment of Providers:

Required. State may use alternative voluntary option of an Organized Health Care delivery System to make payments.

Exception allowed under §447.10 Prohibition against reassignment of provider claims.

§447.10(g)(4): In the case of a class of practitioners for which the Medicaid program is the primary source of service revenue, payment may be made to a third party on behalf of the individual practitioner for benefits such as health insurance, skills training and other benefits customary for employees.

Provider Payments:

Payment item must be listed in the service plan (plan of care), provided by an enrolled provider, and provided prior to reimbursement.

Cost Requirements:

None. Benefit limits may apply.

Quality Management:

Pre-print requires a quality assurance and improvement plan including how state conducts discovery, remediation, and quality improvement.

Interaction with State Plan Services, Waivers & Amendments:

Individuals may be eligible for and receive State plan services, §1915(c), §1915(i), §1915(j)/§1915(k) services simultaneously, so long as the service plan (plan of care) ensures duplication of services is not occurring.